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t y, <br /> r <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: W f Irk, I 111 : CONTACT PHONE#fes_ g-7//7 <br /> FACILITY NAME: ,ill <br /> S r FACILITY PHONE# <br /> FACILITY ADDRESS: l CROSS STREET: f vU ev <br /> OWNER/OPERATOR: G PHONE: Ywy <br /> V1)_ -5 W- �7Z <br /> CONTRACTOR NAME: - PHONE: <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> HAZARDOUS WASTE CERTIFICATE: YES NO WORKERS COMP# <br /> FIRE DISTRICT: 4(- S L PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> ❑APPROVED UA&PROVED WITH CONDITIONS B DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITR SAN JOAQUIN COUNTY O INANCES.STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED.,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS O C IFORNIA.- <br /> APPLICANT'S SIGNATURE <br /> TITLEY��/ DATE <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour <br /> minimum installation payment.The party must acknowledge this responsibility for the additional billing <br /> by signature and date below. <br /> Name (-x I444e n ' /W 44r. !i-Al*l'' Date <br /> Mailing Addres 5-�7 Yqr G' /6,./ t 41/1 �P-4� <br /> Signature a6;4 9/ Daytime Phone 'LS/ <br /> C. REQUIRED SUBMITTALS <br />